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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 <br /> P YEAR rROAL DAIE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby aade,to San Joaquin County for a permit to construct and/or install the work herein described, This <br /> application is made in cowliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules aad Regulations of San <br /> Joaquin Count/yj Public Health Services. <br /> Job Address /// .. nie_UJ60City Lot Size/Acreage <br /> Owner's Name Aa eA1QW 1 Address Onp$�L} Phone S6;Z <br /> Conlractor__S l Address License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION D Out of Service Well 0 <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ [Monitoring Well C7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD, PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ <br /> INTENDED USE. TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> f_7 Industrial O Open Bottom ❑ Manteca Dia, of Well Excavation Dia. of Well Casing <br /> U Domestic/Private D Gravel Pack 0 Tracy Type of Casing Specifications <br /> 0 Public ("I Other ❑ Delta Depth of Grout Seal Type of Grout I <br /> CJ Ifrigarion Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done v T 'y <br /> ypa of Pump H.P. Stasi Work Done <br /> Well Destruction O Well Diameter Sealing ,Material ! Depth <br /> Depth Filler Material i Depth \ <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION❑ REPAIR/ADDITION 0 DESTRUCTION (No septic system permitted if public sewer is <br /> vailable within 200 feet., <br /> installation will serve: Residence— Commercial�, Other � <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK 0 Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. Cl Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/sire <br /> FILTER BED n Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS Ll Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS 0 <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin County <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not <br /> employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of Californla." <br /> The applicant must call for all required inspections. Complete drawing on reverse side. <br /> Signed Title:1 /%' — <br /> rJ, Date: . <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Data �A� Area <br /> Pit or Grout Inspection by Date Final Inspection by <br /> Additlenal Comments: le- O It �_P <br /> Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 495 N SAN JOAQUIN, P O BOX 2009, STOCKTON, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED <br /> 1NF0 RECEIVED eY DATE PERMIT NO. <br /> . EM 13-24 tlIEV.t/K01 L � q G <br /> Ek 1.1.20 ,4?0 <br /> /1 / L.a O'� o / <br />